- Email: [email protected]
Creating and sustaining a collaborative model of care
ORIGINAL ARTICLE
Creating and sustaining a collaborative model of care Marla Fryers, MScN; Linda Young, MScN, EdD; Paula Rowland, BHSc(OT), MA
Abstract—For the past 3 years, Toronto East General Hospital staff and leadership have been involved in the design, implementation, and evaluation of a transformational change to the model of patient care. The purpose of the new model is to enhance quality, safety, and patient satisfaction through a redefinition of our approach to the patient experience. The evaluation framework for the Coordinated Care Team (CCT) model of care addressed safety and quality outcomes, patient satisfaction, staff and physician satisfaction, and resource impact. Results of the evaluation suggest that the introduction of the CCT model using the patient care bundle can have a significant impact on the patient experience through enhanced access to bedside care as well as improved quality and safety outcomes. This article is a follow-up to the article on the development of the model published in Forum (Fall 2009). It extends upon the previous article through an overview of the model as it evolved, a discussion of the first-year evaluation for three pilot units, and lessons learned regarding the change process.
C
hanging a care delivery model involves major transformational work. In a system that is constantly challenged to adapt to changing population needs, advances in medical science and technology, and new legislative requirements, the introduction of a new model of care across a hospital can be daunting. At the same time, the need to assure the optimal use of resources to maintain or enhance the quality of care in healthcare institutions is essential. In 2008, Toronto East General Hospital (TEGH), a 515-bed acute care community teaching hospital undertook a redesign of the model of care delivery to address challenges associated with staffing shortages and staff and patient satisfaction. The design, rationale, and early evaluation results were described in a previous publication.1 This article describes the Coordinated Care Team (CCT) model, providing evaluation results and lessons learned after 1 year of implementation.
THE CCT MODEL Designing the model Under the leadership of the Vice President Programs and Chief Nursing Officer, a large group of staff and management collaboratively designed the CCT model of care based on several sources from the scholarly and practice literature.2⫺8 Guiding principles projected that the new model would meet the needs of the population served; provide a clear delineation of roles and responsibilities for
From the Toronto East General Hospital, Toronto, Ontario, Canada. Corresponding author: Marla Fryers, MScN, Toronto East General Hospital, 825 Coxwell Avenue, Toronto, Ontario M4C 3E7, Canada (e-mail: [email protected]). Healthcare Management Forum 2012 25:20 –25 0840-4704/$ - see front matter © 2012 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.hcmf.2011.11.001
all healthcare providers; leverage redesigned work processes and technology; enhance quality, safety, and patient satisfaction; and foster workplace wellness and enhance staff satisfaction. In the new model, staff would work to their full scope of practice. Overall, the model was expected to achieve positive patient, provider, and system outcomes.
Description of the CCT model The CCT model is based on inter-professional teamwork and a proficient level of coordination among team members. Both core team and extended teams are identified in the model. Core team members typically include registered nurses, registered practical nurses, and patient care assistants. Extended team members include allied health professionals, physician assistants, and physicians. Membership on the core team and extended teams reflects the unique needs of the patient population cared for by the unit. The CCT model was initially implemented on oncology, acute medicine, and surgical units over a 4-month period. Figure 1 depicts the composition of the core team on the three pilot units. Enhanced inter-professional dialogue and the introduction of the patient care bundle are important components of the model. The patient care bundle includes the following: (1) hourly patient care rounds by members of the core team on each patient, (2) daily inter-professional rounds to improve care coordination and team communications, (3) face-to-face inter-professional exchange between shifts, and (4) post-discharge telephone calls to patients within 48 hours of discharge. Based on work by Studer,8 the patient care hourly rounds are structured to address the “4 P’s” with each patient. The “4 P’s” refer to (1) positioning, (2) personal needs including assistance to the bathroom, (3) pain, and (4) the placement of personal items within reach.8
CREATING AND SUSTAINING A COLLABORATIVE MODEL OF CARE F3 Oncology One team caring for 15 patients
RN
CCT Composition
PSW PS RPN PCA
Days & Evenings
1 RN 2 RPN 1 PCA x 1 team
Nights
1 RN 2 RPN 1 PCA x 1 team
RPN
15 patients
B3 Acute Medicine Two teams each caring for 15 patients
and determine if the objectives of the model were being met. Three evaluations were written for the model: at 2 to 3 months, at 5 to 6 months, and at 1 year. This report pertains to the year 1 evaluation for the three pilot units. Table 1 provides background information on each of the pilot units. Four priority areas provided focus for the collection of quantitative and qualitative data: (1) patient safety, (2) patient satisfaction, (3) staff and physician satisfaction, and (4) resource utilization. To ensure that there was a sizable dataset for making observations, quantitative results for the three units were aggregated for a pre-implementation rate that was compared with the rate post-implementation. Results are presented in relation to each priority area.
RN
RN
Patient safety
PSW PS
PSW PS RPN PCA
PCA
RPN
RPN
RPN
CCT Composition Days & Evenings
1 RN 2 RPN 1 PCA x 2 teams
Nights
1 RN 1 RPN x 2 teams
B5 Inpatient Surgery
Patient satisfaction
Two teams of different composition caring for 15 patients RN
RN
PSW PS
PSW PS RPN PCA
PCA
RN
RPN
RPN
Indicators selected for monitoring the impact of the CCT model on patient safety included rates for falls, pressure ulcers, infections, and medication incidents. The evaluation involved comparing monthly rates for 1 year before implementation with those of 1 year after implementation. Data on safety indicators were taken from incident reports and the discharge abstract data. Results show improvement on all measures as presented in Table 2.
CCT Composition Days & Evenings
1 RN 2 RPN 1 PCA x 1 team 2 RN 1 RPN 1 PCA x 1 team
Nights
1 RN 1 RPN x 2 teams
Figure 1. Composition of core team on pilot units.
CCT MODEL PILOT UNIT EVALUATION The Canadian Nurses Association’s Evaluation Framework to Determine the Impact of Nursing Staff Mix Decisions6 guided the development of the evaluation in the context of the parameters of the TEGH strategic plan. The evaluation set out to understand the adequacy of the CCT implementation process; assess the need for additional tools or strategies to support implementation; examine the impact of the model on patient safety, patient satisfaction, staff, and physician satisfaction and resource utilization;
Post-discharge telephone calls made by trained staff within 48 hours of discharge were implemented with the CCT model of care. Patient satisfaction was evaluated by comparing responses to three questions on post-discharge telephone calls with previous National Research Corporation (NRC) Picker Patient Satisfaction Survey responses to the questions. A total of 572 patients provided feedback (17.7%). Patient complaints registered with the patient relations office over the 2-year pre-/post-period were also used to evaluate patient satisfaction. Results are described in Table 3. Although overall scores showed improvement, unit specific data indicated that the medical unit was struggling with the response time to call bells. Consequently, additional staff members were added to the day shift, resulting in an improvement in patient satisfaction scores. From a qualitative perspective, patients’ comments made during discharge telephone calls highlighted the benefits of the CCT model as follows: 1. Attentiveness: “Nurses were very attentive and the person who provided personal care was wonderful . . . the care was great!” 2. Quality of care: “I am in awe of the wonderful nursing care I received while I was there as a patient.” 3. Teamwork: “All the nurses were excellent. I liked knowing that the team knew my case well.”
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
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Fryers, Young, and Rowland
Table 1. Overview of pilot units
Beds Patient discharges Patient days Average length of stay Average resource intensity weight Occupancy rate (%)
Oncology
Acute Medicine
Surgery
Total/Average
15 533 5,433 10.2 1.86 99
30 662 9,560 13.1 2.08 87
29 2,025 8,213 4.0 1.32 78
74 3,220 23,206 7.2 1.75 86
Data based on discharge abstract database for 12 months post-implementation.
4. Support: “They all made us feel welcomed. The nurses all introduced themselves . . . If we are ever readmitted, we want to go back to this unit.” Patients suggested that patient satisfaction could be enhanced by more informed discharge planning, improving staff communication skills, decreasing noise at night, and shorter stays in emergency.
Staff and physician satisfaction The evaluation of staff satisfaction was based on two or more focus groups held on each unit on different shifts. A total of 39 staff (41%) participated, including 16 registered nurses, 10 registered practical nurses, 10 personal care assistants, and three others (allied health professionals or clerical staff). Responses were analysed under five areas of focus identified from the transcripts including adjusting to a new way of working, team functioning, the impact on patients and families, unit processes and workload, and scope of practice. 1. Adjusting to a new way of working: most staff indicated that they are comfortable in the new model of care rating their comfort level as 7 to 9 on a scale of 1 to 10, where 10 means absolutely comfortable. Their comments highlighted the need to learn “new ways to work” as well as the challenges of working with some nurses who “are reluctant to let go of the previous model and their past role.” 2. Team functioning: the staff identified that they are more aware of the need to work together and to rely
on each other. They observed that good inter-personal relations including respect, effective communication, recognizing each other’s strengths, supporting each other, explaining things, and celebrating contribute to optimal team functioning. Continuity in team membership and physicians or physician assistant participation in rounds was highly beneficial to workflow and team effectiveness. Suggestions for improvement included more relationship building on some teams and further development of communications skills. 3. Impact on patients and families: benefits to the CCT model included access to staff, hourly rounding, teamwork, and patient satisfaction. Staff commented “Patients are accessing different staff, they appreciate talking to different people” and “there is increased patient satisfaction because we are working as one, it’s more fluid . . . someone is always there with the patient.” 4. Unit processes and workload: staff underlined the value of a strong team leader who could rebalance work assignments, noting the difference this made to team effectiveness and staff satisfaction. Unpredictable work such as demands from patients or families, changing patient acuity, and volume surges associated with patient flow were often a stressor for teams. Workload challenges meant that sometimes teams were not able to complete patient rounds on an hourly basis. Workload stress was more evident when other changes occurred in close succession with CCT. 5. Scope of practice: some nurses were not practicing at full scope 1 year after implementation. Gaps included
Table 2. Patient safety indicators
Indicator
1-year pre-CCT implementation
1-year post CCT implementation
Falls (rate per 1,000 patient days) Post admit pressure ulcers ⬎70 years of age (rate per 1,000 patient days) Medication incidents (rate per 1,000 doses) Patient to patient transmission of infection (rate per 1,000 patient days)
7.1 0.25 0.64 0.18
4.9 0.17 0.43 0.13
22
Difference Reduced Reduced Reduced Reduced
by by by by
31% 32% 33% 28%
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
CREATING AND SUSTAINING A COLLABORATIVE MODEL OF CARE
Table 3. Patient satisfaction
Availability of nurse rated as good, very good, or excellent (% patients reporting) Always had help to bathroom on time (% patients reporting) Time waiting for call bell response was always reasonable (% patients reporting) Patient complaints (number of complaints)
team leadership and organizational skills, competence with nursing skills such as intravenous starts, and the development of critical thinking skills associated with expanded scope. Physician evaluation data were unavailable at 1 year because of a low response rate to the electronic survey. Data at 6 months (N ⫽ 14) indicated modest improvements in quality of care (29%), teamwork (50%), and reduction in patient complaints (14%). Areas for ongoing development at 6 months included ease of access to information from nurses and making appropriate referrals to allied team members. Physicians continue to be supportive of the change.
Resource utilization Measures used to assess the resource impact of the CCT model included changes in overtime, agency use, illness hours, the use of constant care aids, and direct patient-care hours. Pre-/post-comparisons used data from financial and payroll systems. Results are identified in Table 4. The CCT model provided an average increase of 66 minutes of care per patient per day. Increases in the use of overtime and agency staff were attributed to the need to backfill staff during CCT training and are expected to stabilize over time. Constant care aids were needed less frequently to monitor confused patients or those identified as a falls risk.
1-year pre-CCT implementation
1-year post CCT implementation
Difference
78
89
Improved by 14%
49
77
Improved by 57%
57 43
68 33
Improved by 19% Reduced by 23%
DISCUSSION The evaluation results provide evidence that the CCT model as implemented at TEGH has been beneficial for patient care in relation to patient safety outcomes and patient satisfaction measures. These improvements are in keeping with reports of success with similar changes in other hospitals.8⫺11 Staff feedback underlined the time it takes to adapt to the new model and the challenges remaining after 1 year. Ongoing education, coaching, and guidance are still needed to assist staff with achieving the full scope of practice, managing workload issues, enhancing team leader effectiveness, and facilitating inter-professional collaboration. Although specific team leader workshops have been implemented, additional work is still required. TEGH has implemented the CCT model on a total of 13 inpatient units including general and specialty units across the hospital. A modified model is also used in the emergency department. CCT indicators are being assessed through the corporate scorecard to monitor sustainability.
LESSONS LEARNED Designing, implementing, evaluating, and sustaining this change has been a complex endeavour involving the input and commitment of a diverse range of stakeholders. The following “lessons learned” are an indication of the leadership strategies required to implement and sustain this kind of organizational change.
Table 4. Resource utilization
Indicator Direct patient care, hours Illness hours Agency Overtime Constant care aids
1-year pre-CCT implementation
1-year post CCT implementation
Difference
116,861 5,366 $22,270 $103,389
142,476 4,850 $23,741 $126,762
Increased by 22% Decreased by 10% Increased by 6.8% Increased by 23%
$246,127
$86,413
Decreased by 65%
Support from all levels of the organization throughout design, implementation, evaluation, and sustainability The change process required to implement the CCT model has been substantive. Implementation of the model cannot be successful without consistent engagement from all levels of the organization. This includes support from the board, the executive team, directors, managers, supervisors, and frontline service providers throughout the change.
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Fryers, Young, and Rowland
Support includes ensuring time for dialogue and reflection to understand and manage the emergent change process. Monthly meetings with directors, managers, and supervisors from all levels provided a forum for this dialogue throughout planning and implementation. Support also involves ongoing communication and guiding teams through staffing changes and project management revisions. Support from labour relations and communications staff is critical to the success of the change.
assign a dedicated resource to oversee the program evaluation. Finally, while providing a coherent fit with our change leadership strategy, this developmental approach made for a difficult translation into venues expecting a summative evaluation in the very early stages of implementation. Setting realistic expectations with stakeholders regarding the evaluation strategy with ongoing communication is essential.
Adequate resources for all phases For the change to CCT, organizational leaders need to secure the appropriate resources to allow for design work, ongoing training for frontline staff, and project evaluation. Each of these required a significant investment of human resources, coordination, and focused effort that should not be underestimated. In addition, frontline staff must be actively engaged in ongoing rapid improvement cycles to refine unit practices to support meaningful implementation of the CCT model. Unit level customization includes refining the language and schedules for hourly patient rounds and the processes for initial and inter-professional rounds. Successful customization requires an investment of time and an enhancement of skills related to quality improvement work for both managers and frontline staff.
Service-oriented design Service-oriented principles guided the design of this project from its inception. A collective orientation toward the needs of the patient allowed for creativity in design and freedom from intra- and inter-professional tensions that emerge in provider centric conversations. Refocusing discussions on the principles of service-oriented design was an essential success factor throughout the project.
Change leadership and program evaluation As already mentioned, this change requires an emergent approach. As TEGH moved from design to implementation to sustainability, the needs of staff shifted. The success of the model relies on the ability for staff and management to continually learn from the implementation process and to be sensitive to changing trends. For the purposes of this project, the program evaluation design was based on the principles of collective learning. This framing allowed TEGH to be responsive to the emerging data and to make course corrections along the way. This approach required a significant volume of continual data collection to access timely information. Data were drawn from several sources throughout the hospital, thereby requiring a substantial effort to ensure the timely, coordinated, and accurate flow of information for the evaluation. To manage this complexity, it was necessary to 24
NEXT STEPS The implementation of the CCT model attended to the structures and processes of our model of care. Our change strategy has also provided the foundation for staff and management to make full use of the tools, technologies, and resources associated with continuous quality improvement to further refine inter-professional teamwork and enhance the patient experience. Units have begun the process of adopting and implementing organized unit initiatives, patient at-a-glance boards, and daily inter-professional huddles to review key metrics related to patient care. In the coming months, we will continue to evolve our model of care by streamlining admission, care planning, and discharge planning processes based on inter-professional standards of practice. These changes will provide the groundwork for leveraging technology to improve workload management through the implementation of redesigned documentation tools and an electronic patient record.
CONCLUSIONS The CCT model was created through a collective design process, providing a model of care that is sensitive to existing trends while being customized to the local context of TEGH. The change required to implement and sustain this model is highly complex, and the success of the emergent change strategy is reliant on support from all levels of the organization, ensuring resources to support the change process and maintaining a service-oriented design and collective learning. The improvements in patient, provider, and organizational outcomes provide a compelling argument that increased quality can be achieved with innovative thinking applied within existing resources. Looking ahead, the CCT model lays the foundation for leveraging inter-professional teamwork and technology to enhance the patient experience.
ACKNOWLEDGMENTS The authors would like to acknowledge the extensive contributions made by staff and physicians at TEGH to the design, implementation, and evaluation of the CCT model.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
CREATING AND SUSTAINING A COLLABORATIVE MODEL OF CARE
REFERENCES 1. Campbell B, Fryers M, Devitt R, et al. Towards a collaborative model of care. Healthc Manage Forum 2009;22:27–31. 2. Bauman A, Blythe J, Baxter P, et al. Registered practical nurses: an overview of education and practice. A report to the Implementation Task Force, Ontario Ministry of Health and Long Term Care. Toronto: Government of Ontario; 2009. 3. College of Nurses of Ontario. Practice Expectations: A Guide for the Utilization of RNs and RPNs. Toronto, ON: Author; 2002. 4. College of Nurses of Ontario. Utilization of unregulated Care Providers (UCPs): A Guide to Making Decisions. Toronto, ON: Author; 2008. 5. College of Nurses of Ontario. The Regulated Health Professions Act Part B: Scope of Practice, Controlled Acts Model. Toronto, ON: Author; 2003. 6. Canadian Nurses Association. Framework to Determine the Impact of Staff Mix Decisions. Ottawa, ON: Author; 2006.
7. Pan-Canadian Planning Committee on Unregulated Health Workers. Maximizing Health Human Resources: Valuing Unregulated Health Workers. Highlights of the 2009 Pan-Canadian Symposium: Ottawa, ON: Canadian Nurses Association; 2009. 8. Studer Q. Results That Last: Hardwiring Behaviors That Will Take Your Company to the Top. Hoboken, NJ: John Wiley and Sons; 2008. 9. Kimball B, Cherner D, Joynt J, et al. The quest for new innovative care delivery models. J Nurs Adm 2007;37: 392– 8. 10. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds on patient’s light use, satisfaction, and safety. Am J Nurs 2006;106:58 –70. 11. Setia N, Meade C. Bundling the value of discharge telephone calls and Leader rounding. J Nurs Adm 2009;39:138 – 141.
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Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
25
Creating and sustaining a collaborative model of care Marla Fryers, MScN; Linda Young, MScN, EdD; Paula Rowland, BHSc(OT), MA
Abstract—For the past 3 years, Toronto East General Hospital staff and leadership have been involved in the design, implementation, and evaluation of a transformational change to the model of patient care. The purpose of the new model is to enhance quality, safety, and patient satisfaction through a redefinition of our approach to the patient experience. The evaluation framework for the Coordinated Care Team (CCT) model of care addressed safety and quality outcomes, patient satisfaction, staff and physician satisfaction, and resource impact. Results of the evaluation suggest that the introduction of the CCT model using the patient care bundle can have a significant impact on the patient experience through enhanced access to bedside care as well as improved quality and safety outcomes. This article is a follow-up to the article on the development of the model published in Forum (Fall 2009). It extends upon the previous article through an overview of the model as it evolved, a discussion of the first-year evaluation for three pilot units, and lessons learned regarding the change process.
C
hanging a care delivery model involves major transformational work. In a system that is constantly challenged to adapt to changing population needs, advances in medical science and technology, and new legislative requirements, the introduction of a new model of care across a hospital can be daunting. At the same time, the need to assure the optimal use of resources to maintain or enhance the quality of care in healthcare institutions is essential. In 2008, Toronto East General Hospital (TEGH), a 515-bed acute care community teaching hospital undertook a redesign of the model of care delivery to address challenges associated with staffing shortages and staff and patient satisfaction. The design, rationale, and early evaluation results were described in a previous publication.1 This article describes the Coordinated Care Team (CCT) model, providing evaluation results and lessons learned after 1 year of implementation.
THE CCT MODEL Designing the model Under the leadership of the Vice President Programs and Chief Nursing Officer, a large group of staff and management collaboratively designed the CCT model of care based on several sources from the scholarly and practice literature.2⫺8 Guiding principles projected that the new model would meet the needs of the population served; provide a clear delineation of roles and responsibilities for
From the Toronto East General Hospital, Toronto, Ontario, Canada. Corresponding author: Marla Fryers, MScN, Toronto East General Hospital, 825 Coxwell Avenue, Toronto, Ontario M4C 3E7, Canada (e-mail: [email protected]). Healthcare Management Forum 2012 25:20 –25 0840-4704/$ - see front matter © 2012 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.hcmf.2011.11.001
all healthcare providers; leverage redesigned work processes and technology; enhance quality, safety, and patient satisfaction; and foster workplace wellness and enhance staff satisfaction. In the new model, staff would work to their full scope of practice. Overall, the model was expected to achieve positive patient, provider, and system outcomes.
Description of the CCT model The CCT model is based on inter-professional teamwork and a proficient level of coordination among team members. Both core team and extended teams are identified in the model. Core team members typically include registered nurses, registered practical nurses, and patient care assistants. Extended team members include allied health professionals, physician assistants, and physicians. Membership on the core team and extended teams reflects the unique needs of the patient population cared for by the unit. The CCT model was initially implemented on oncology, acute medicine, and surgical units over a 4-month period. Figure 1 depicts the composition of the core team on the three pilot units. Enhanced inter-professional dialogue and the introduction of the patient care bundle are important components of the model. The patient care bundle includes the following: (1) hourly patient care rounds by members of the core team on each patient, (2) daily inter-professional rounds to improve care coordination and team communications, (3) face-to-face inter-professional exchange between shifts, and (4) post-discharge telephone calls to patients within 48 hours of discharge. Based on work by Studer,8 the patient care hourly rounds are structured to address the “4 P’s” with each patient. The “4 P’s” refer to (1) positioning, (2) personal needs including assistance to the bathroom, (3) pain, and (4) the placement of personal items within reach.8
CREATING AND SUSTAINING A COLLABORATIVE MODEL OF CARE F3 Oncology One team caring for 15 patients
RN
CCT Composition
PSW PS RPN PCA
Days & Evenings
1 RN 2 RPN 1 PCA x 1 team
Nights
1 RN 2 RPN 1 PCA x 1 team
RPN
15 patients
B3 Acute Medicine Two teams each caring for 15 patients
and determine if the objectives of the model were being met. Three evaluations were written for the model: at 2 to 3 months, at 5 to 6 months, and at 1 year. This report pertains to the year 1 evaluation for the three pilot units. Table 1 provides background information on each of the pilot units. Four priority areas provided focus for the collection of quantitative and qualitative data: (1) patient safety, (2) patient satisfaction, (3) staff and physician satisfaction, and (4) resource utilization. To ensure that there was a sizable dataset for making observations, quantitative results for the three units were aggregated for a pre-implementation rate that was compared with the rate post-implementation. Results are presented in relation to each priority area.
RN
RN
Patient safety
PSW PS
PSW PS RPN PCA
PCA
RPN
RPN
RPN
CCT Composition Days & Evenings
1 RN 2 RPN 1 PCA x 2 teams
Nights
1 RN 1 RPN x 2 teams
B5 Inpatient Surgery
Patient satisfaction
Two teams of different composition caring for 15 patients RN
RN
PSW PS
PSW PS RPN PCA
PCA
RN
RPN
RPN
Indicators selected for monitoring the impact of the CCT model on patient safety included rates for falls, pressure ulcers, infections, and medication incidents. The evaluation involved comparing monthly rates for 1 year before implementation with those of 1 year after implementation. Data on safety indicators were taken from incident reports and the discharge abstract data. Results show improvement on all measures as presented in Table 2.
CCT Composition Days & Evenings
1 RN 2 RPN 1 PCA x 1 team 2 RN 1 RPN 1 PCA x 1 team
Nights
1 RN 1 RPN x 2 teams
Figure 1. Composition of core team on pilot units.
CCT MODEL PILOT UNIT EVALUATION The Canadian Nurses Association’s Evaluation Framework to Determine the Impact of Nursing Staff Mix Decisions6 guided the development of the evaluation in the context of the parameters of the TEGH strategic plan. The evaluation set out to understand the adequacy of the CCT implementation process; assess the need for additional tools or strategies to support implementation; examine the impact of the model on patient safety, patient satisfaction, staff, and physician satisfaction and resource utilization;
Post-discharge telephone calls made by trained staff within 48 hours of discharge were implemented with the CCT model of care. Patient satisfaction was evaluated by comparing responses to three questions on post-discharge telephone calls with previous National Research Corporation (NRC) Picker Patient Satisfaction Survey responses to the questions. A total of 572 patients provided feedback (17.7%). Patient complaints registered with the patient relations office over the 2-year pre-/post-period were also used to evaluate patient satisfaction. Results are described in Table 3. Although overall scores showed improvement, unit specific data indicated that the medical unit was struggling with the response time to call bells. Consequently, additional staff members were added to the day shift, resulting in an improvement in patient satisfaction scores. From a qualitative perspective, patients’ comments made during discharge telephone calls highlighted the benefits of the CCT model as follows: 1. Attentiveness: “Nurses were very attentive and the person who provided personal care was wonderful . . . the care was great!” 2. Quality of care: “I am in awe of the wonderful nursing care I received while I was there as a patient.” 3. Teamwork: “All the nurses were excellent. I liked knowing that the team knew my case well.”
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
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Fryers, Young, and Rowland
Table 1. Overview of pilot units
Beds Patient discharges Patient days Average length of stay Average resource intensity weight Occupancy rate (%)
Oncology
Acute Medicine
Surgery
Total/Average
15 533 5,433 10.2 1.86 99
30 662 9,560 13.1 2.08 87
29 2,025 8,213 4.0 1.32 78
74 3,220 23,206 7.2 1.75 86
Data based on discharge abstract database for 12 months post-implementation.
4. Support: “They all made us feel welcomed. The nurses all introduced themselves . . . If we are ever readmitted, we want to go back to this unit.” Patients suggested that patient satisfaction could be enhanced by more informed discharge planning, improving staff communication skills, decreasing noise at night, and shorter stays in emergency.
Staff and physician satisfaction The evaluation of staff satisfaction was based on two or more focus groups held on each unit on different shifts. A total of 39 staff (41%) participated, including 16 registered nurses, 10 registered practical nurses, 10 personal care assistants, and three others (allied health professionals or clerical staff). Responses were analysed under five areas of focus identified from the transcripts including adjusting to a new way of working, team functioning, the impact on patients and families, unit processes and workload, and scope of practice. 1. Adjusting to a new way of working: most staff indicated that they are comfortable in the new model of care rating their comfort level as 7 to 9 on a scale of 1 to 10, where 10 means absolutely comfortable. Their comments highlighted the need to learn “new ways to work” as well as the challenges of working with some nurses who “are reluctant to let go of the previous model and their past role.” 2. Team functioning: the staff identified that they are more aware of the need to work together and to rely
on each other. They observed that good inter-personal relations including respect, effective communication, recognizing each other’s strengths, supporting each other, explaining things, and celebrating contribute to optimal team functioning. Continuity in team membership and physicians or physician assistant participation in rounds was highly beneficial to workflow and team effectiveness. Suggestions for improvement included more relationship building on some teams and further development of communications skills. 3. Impact on patients and families: benefits to the CCT model included access to staff, hourly rounding, teamwork, and patient satisfaction. Staff commented “Patients are accessing different staff, they appreciate talking to different people” and “there is increased patient satisfaction because we are working as one, it’s more fluid . . . someone is always there with the patient.” 4. Unit processes and workload: staff underlined the value of a strong team leader who could rebalance work assignments, noting the difference this made to team effectiveness and staff satisfaction. Unpredictable work such as demands from patients or families, changing patient acuity, and volume surges associated with patient flow were often a stressor for teams. Workload challenges meant that sometimes teams were not able to complete patient rounds on an hourly basis. Workload stress was more evident when other changes occurred in close succession with CCT. 5. Scope of practice: some nurses were not practicing at full scope 1 year after implementation. Gaps included
Table 2. Patient safety indicators
Indicator
1-year pre-CCT implementation
1-year post CCT implementation
Falls (rate per 1,000 patient days) Post admit pressure ulcers ⬎70 years of age (rate per 1,000 patient days) Medication incidents (rate per 1,000 doses) Patient to patient transmission of infection (rate per 1,000 patient days)
7.1 0.25 0.64 0.18
4.9 0.17 0.43 0.13
22
Difference Reduced Reduced Reduced Reduced
by by by by
31% 32% 33% 28%
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
CREATING AND SUSTAINING A COLLABORATIVE MODEL OF CARE
Table 3. Patient satisfaction
Availability of nurse rated as good, very good, or excellent (% patients reporting) Always had help to bathroom on time (% patients reporting) Time waiting for call bell response was always reasonable (% patients reporting) Patient complaints (number of complaints)
team leadership and organizational skills, competence with nursing skills such as intravenous starts, and the development of critical thinking skills associated with expanded scope. Physician evaluation data were unavailable at 1 year because of a low response rate to the electronic survey. Data at 6 months (N ⫽ 14) indicated modest improvements in quality of care (29%), teamwork (50%), and reduction in patient complaints (14%). Areas for ongoing development at 6 months included ease of access to information from nurses and making appropriate referrals to allied team members. Physicians continue to be supportive of the change.
Resource utilization Measures used to assess the resource impact of the CCT model included changes in overtime, agency use, illness hours, the use of constant care aids, and direct patient-care hours. Pre-/post-comparisons used data from financial and payroll systems. Results are identified in Table 4. The CCT model provided an average increase of 66 minutes of care per patient per day. Increases in the use of overtime and agency staff were attributed to the need to backfill staff during CCT training and are expected to stabilize over time. Constant care aids were needed less frequently to monitor confused patients or those identified as a falls risk.
1-year pre-CCT implementation
1-year post CCT implementation
Difference
78
89
Improved by 14%
49
77
Improved by 57%
57 43
68 33
Improved by 19% Reduced by 23%
DISCUSSION The evaluation results provide evidence that the CCT model as implemented at TEGH has been beneficial for patient care in relation to patient safety outcomes and patient satisfaction measures. These improvements are in keeping with reports of success with similar changes in other hospitals.8⫺11 Staff feedback underlined the time it takes to adapt to the new model and the challenges remaining after 1 year. Ongoing education, coaching, and guidance are still needed to assist staff with achieving the full scope of practice, managing workload issues, enhancing team leader effectiveness, and facilitating inter-professional collaboration. Although specific team leader workshops have been implemented, additional work is still required. TEGH has implemented the CCT model on a total of 13 inpatient units including general and specialty units across the hospital. A modified model is also used in the emergency department. CCT indicators are being assessed through the corporate scorecard to monitor sustainability.
LESSONS LEARNED Designing, implementing, evaluating, and sustaining this change has been a complex endeavour involving the input and commitment of a diverse range of stakeholders. The following “lessons learned” are an indication of the leadership strategies required to implement and sustain this kind of organizational change.
Table 4. Resource utilization
Indicator Direct patient care, hours Illness hours Agency Overtime Constant care aids
1-year pre-CCT implementation
1-year post CCT implementation
Difference
116,861 5,366 $22,270 $103,389
142,476 4,850 $23,741 $126,762
Increased by 22% Decreased by 10% Increased by 6.8% Increased by 23%
$246,127
$86,413
Decreased by 65%
Support from all levels of the organization throughout design, implementation, evaluation, and sustainability The change process required to implement the CCT model has been substantive. Implementation of the model cannot be successful without consistent engagement from all levels of the organization. This includes support from the board, the executive team, directors, managers, supervisors, and frontline service providers throughout the change.
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Fryers, Young, and Rowland
Support includes ensuring time for dialogue and reflection to understand and manage the emergent change process. Monthly meetings with directors, managers, and supervisors from all levels provided a forum for this dialogue throughout planning and implementation. Support also involves ongoing communication and guiding teams through staffing changes and project management revisions. Support from labour relations and communications staff is critical to the success of the change.
assign a dedicated resource to oversee the program evaluation. Finally, while providing a coherent fit with our change leadership strategy, this developmental approach made for a difficult translation into venues expecting a summative evaluation in the very early stages of implementation. Setting realistic expectations with stakeholders regarding the evaluation strategy with ongoing communication is essential.
Adequate resources for all phases For the change to CCT, organizational leaders need to secure the appropriate resources to allow for design work, ongoing training for frontline staff, and project evaluation. Each of these required a significant investment of human resources, coordination, and focused effort that should not be underestimated. In addition, frontline staff must be actively engaged in ongoing rapid improvement cycles to refine unit practices to support meaningful implementation of the CCT model. Unit level customization includes refining the language and schedules for hourly patient rounds and the processes for initial and inter-professional rounds. Successful customization requires an investment of time and an enhancement of skills related to quality improvement work for both managers and frontline staff.
Service-oriented design Service-oriented principles guided the design of this project from its inception. A collective orientation toward the needs of the patient allowed for creativity in design and freedom from intra- and inter-professional tensions that emerge in provider centric conversations. Refocusing discussions on the principles of service-oriented design was an essential success factor throughout the project.
Change leadership and program evaluation As already mentioned, this change requires an emergent approach. As TEGH moved from design to implementation to sustainability, the needs of staff shifted. The success of the model relies on the ability for staff and management to continually learn from the implementation process and to be sensitive to changing trends. For the purposes of this project, the program evaluation design was based on the principles of collective learning. This framing allowed TEGH to be responsive to the emerging data and to make course corrections along the way. This approach required a significant volume of continual data collection to access timely information. Data were drawn from several sources throughout the hospital, thereby requiring a substantial effort to ensure the timely, coordinated, and accurate flow of information for the evaluation. To manage this complexity, it was necessary to 24
NEXT STEPS The implementation of the CCT model attended to the structures and processes of our model of care. Our change strategy has also provided the foundation for staff and management to make full use of the tools, technologies, and resources associated with continuous quality improvement to further refine inter-professional teamwork and enhance the patient experience. Units have begun the process of adopting and implementing organized unit initiatives, patient at-a-glance boards, and daily inter-professional huddles to review key metrics related to patient care. In the coming months, we will continue to evolve our model of care by streamlining admission, care planning, and discharge planning processes based on inter-professional standards of practice. These changes will provide the groundwork for leveraging technology to improve workload management through the implementation of redesigned documentation tools and an electronic patient record.
CONCLUSIONS The CCT model was created through a collective design process, providing a model of care that is sensitive to existing trends while being customized to the local context of TEGH. The change required to implement and sustain this model is highly complex, and the success of the emergent change strategy is reliant on support from all levels of the organization, ensuring resources to support the change process and maintaining a service-oriented design and collective learning. The improvements in patient, provider, and organizational outcomes provide a compelling argument that increased quality can be achieved with innovative thinking applied within existing resources. Looking ahead, the CCT model lays the foundation for leveraging inter-professional teamwork and technology to enhance the patient experience.
ACKNOWLEDGMENTS The authors would like to acknowledge the extensive contributions made by staff and physicians at TEGH to the design, implementation, and evaluation of the CCT model.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
CREATING AND SUSTAINING A COLLABORATIVE MODEL OF CARE
REFERENCES 1. Campbell B, Fryers M, Devitt R, et al. Towards a collaborative model of care. Healthc Manage Forum 2009;22:27–31. 2. Bauman A, Blythe J, Baxter P, et al. Registered practical nurses: an overview of education and practice. A report to the Implementation Task Force, Ontario Ministry of Health and Long Term Care. Toronto: Government of Ontario; 2009. 3. College of Nurses of Ontario. Practice Expectations: A Guide for the Utilization of RNs and RPNs. Toronto, ON: Author; 2002. 4. College of Nurses of Ontario. Utilization of unregulated Care Providers (UCPs): A Guide to Making Decisions. Toronto, ON: Author; 2008. 5. College of Nurses of Ontario. The Regulated Health Professions Act Part B: Scope of Practice, Controlled Acts Model. Toronto, ON: Author; 2003. 6. Canadian Nurses Association. Framework to Determine the Impact of Staff Mix Decisions. Ottawa, ON: Author; 2006.
7. Pan-Canadian Planning Committee on Unregulated Health Workers. Maximizing Health Human Resources: Valuing Unregulated Health Workers. Highlights of the 2009 Pan-Canadian Symposium: Ottawa, ON: Canadian Nurses Association; 2009. 8. Studer Q. Results That Last: Hardwiring Behaviors That Will Take Your Company to the Top. Hoboken, NJ: John Wiley and Sons; 2008. 9. Kimball B, Cherner D, Joynt J, et al. The quest for new innovative care delivery models. J Nurs Adm 2007;37: 392– 8. 10. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds on patient’s light use, satisfaction, and safety. Am J Nurs 2006;106:58 –70. 11. Setia N, Meade C. Bundling the value of discharge telephone calls and Leader rounding. J Nurs Adm 2009;39:138 – 141.
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Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
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